Friday, October 06, 2006

Bloggers respond on ER overcrowding

In response to my post on ER overcrowding DB notes that the Institute of Medicine (IOM) is unrealistic on many issues and points out the relationship of ER overcrowding to under compensation of general ambulatory care. Increasing utilization of the ER as a “clinic” by patients without access to primary physicians overtaxes emergency care. Worse, some ER patients require hospital admission largely due to the shortage of clinic doctors and inordinate wait times which preclude expeditious out patient work ups.

Today Grunt Doc offered a dissenting view and said (referring to DB, Kevin and myself): “The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles. We're doing that.” I guess I pushed the wrong button here, but no such subtext was intended. I was being critical of the IOM, not emergency departments. I have no doubt they’re doing the best they can.

He made this comment over at DB’s blog: “I think there’s a lot of arrogance in absolving the hospital of any responsibility to ease ED overcrowding. Overcrowding isn’t a result of ED inefficiencies, it’s a lack of hospital ownership of the patients admitted to the hospital through their own ED.” Wait a minute---nobody’s blaming the ER here. This isn’t “us against them.” The emergency department is part of the hospital. Their problems are the hospital’s problems, and vice versa. If the ER is overtaxed the entire hospital feels the strain due to extensive overlap and sharing of resources.

What’s Grunt Doc’s solution? Hallway beds. Fine. It seems to work at his institution. I’m not exactly sure what the hallway protocol entails, but I suppose it means that if all regular beds are occupied (hospital “full”) you put the patients where ever there’s physical space, initiate care and hold them there until a regular bed opens up. To me that’s a form of boarding, but you do what you have to do. There’s nothing written in stone in my mind that such boarding has to take place in the ER unless the patient needs cardiac monitoring.

But hallway boarding has its problems too. If the hospital has reached the capacity of its licensed beds (presumably the case if its wards are really full) might those hallway admissions run afoul of the law? In many cases it’s about more than licensed beds and physical space----it’s about staffing. That’s a patient safety issue. There’s plenty of evidence that higher patient to nurse ratios are associated with increased mortality. In this study, for example, 30 day mortality rose 7% for each patient added per nurse.

I’ll say it again. My whole point was directed at the IOM. They say hospitals wouldn’t have to divert or “board” if they’d just be more efficient. That is simplistic. Hospital administrators, physicians and case managers have been working their fannies off to make hospitals more efficient under draconian negative cost incentives (AKA DRGs) that have been in place for 23 years. That is not the answer to ER crowding.

Related criticisms of IOM:

The hyping of medical errors.

The promotion of pseudoscience.


Allen said...

Dr. RW,
Thanks for the clarification, and my apologies that I didn't see your criticisms of the IOM as just of them and not us in the ED. I rankle easily, but you knew that. The good news is that with my ED attention span I'll have forgotten by tomorrow.

Frankly, hallway boarding is a temporizing measure. I think we need a lot more inpatient beds in the country, but until running hospitals is actually a profitable enterprise we won't see that happen.


Anonymous said...

The IOM is basically a government agency whose aim seems to be to find fault with and criticize health care professionals without having to find the means to properly fund their mandates. They make headlines and take the public's attention away from the real issues of healthcare economics. Our various professional organizations are afraid to refute their findings because we don't want to sound like we're whining. Yet we had better do so or all we're going to see is continued finger pointing and no real change.

Ryan said...

I'd have to agree with GruntDoc on this one. Hospitals too often use EDs as overflow, allowing them to fill, whil protecting the inpatient units.

"But hallway boarding has its problems too. If the hospital has reached the capacity of its licensed beds might those hallway admissions run afoul of the law?"
- My question to you is why are my halls better then your halls? The ED is a loud, chaotic place and patients sitting in the halls get to see all of the action. By sending patients to the floor hall they are in a relatively quiter, calmer, more stable environment; and are more likely to get the care they need, for example a cardiac patient in the hall of a cardiac floor.

"it’s about staffing. That’s a patient safety issue. There’s plenty of evidence that higher patient to nurse ratios are associated with increased mortality."
-I ask agin why floor nurses are different from the ED nurses. By moving patients out of the ED and distributing them across a hospital you dilute the effect of overcrowding, and stabilize ratios. Multiple studies have shown that overcrowded EDs lead to increased morbidity and mortality.

Finally I suggest that floor nurses are more likely to get patients a room if the patient and their family are sitting in the hall watching them. There is no incentive to move patients or clean rooms.

R. W. Donnell said...

You either speed read my post or I'm *really* lousy at explaining things. When I discussed hallway boarding I thought I made it abundantly clear that it didn't matter whose hallway. This is NOT an issue of your vs mine. my criticism was of the IOM, not of emergency departments. I guess I'll have to post another clarification.